Caregivers of older people have been the object of research in the field of gerontology1, 2, 3, 4, 5 due mainly to the increase in the population of older people and the prevalence of chronic non-communicable diseases (e.g., diabetes mellitus, arterial hypertension, dementia and Alzheimer's disease) throughout the world.6,7 Such conditions can lead older people to the need for a caregiver,8 who may be characterized as unpaid (e.g., relative, friend or neighbor) or paid (e.g., nurse, nursing technician or individual having taken a caregiving course).9

Care provided to an older person, which is normally concomitant to other activities performed in daily living (e.g., taking care of the home and children), can have psychological impacts (e.g., burden, burnout and stress) and physical impacts (e.g., difficulty sleeping and pain in the body).10 The main factors associated with the negative impacts of providing care to an older person are functional dependence (the degree of difficulty that the older person has in performing activities of daily living, such as feeding, bathing, changing clothes and managing one's own finances),11 the severity of the disease and/or cognitive impairment (e.g., advanced stage dementia)12 and the lack of social support (e.g., affective, emotional and financial) for the caregiver.13

Unpaid caregivers of older people experience greater negative psychological and physical impacts compared to paid caregivers.4,14 However, both types of caregivers can experience negative impacts.2,14 Due to the occurrence of such problems, non-pharmacological interventions have been conducted with the aim of minimizing harm to caregivers related to the act of providing care.15 Such interventions are diverse, with a focus on mindfulness,3 behavioral activation,16 psychoeducation,17 psychosocial aspects,18 etc. Another type of intervention that has been conducted more recently with caregivers of older people has a focus on empathic ability.19

Empathy is a multidimensional construct that encompasses different emotional, behavioral and cognitive aspects.20, 21, 22, 23 The two main domains of the empathy are affective and cognitive.20,21 Affective empathy regards the capacity of individuals (e.g., caregivers of older people) to put themselves in the place of others (e.g., older people) and feel the same sentiments and emotions, whereas cognitive empathy regards understanding the emotions and feelings of others, but enables the individual not to become caught up in these feelings.20,21 Sociodemographic characteristics of individuals who provide care can contribute to greater levels of empathy (e.g., being a woman, being married, an older age, etc.).4,24

A recent systematic review demonstrated that affective empathy in caregivers of older people is associated with psychological concerns (e.g., burden, depression, anxiety, stress and burnout syndrome), whereas cognitive empathy is inversely associated with such concerns.25 Moreover, the cognitive domain of empathy is directly associated with emotional regulation, whereas the affective domain is inversely associated.26 Training in cognitive empathy has been considered, as this domain involves processes that can be acquired consciously, while the affective domain is considered to be more autonomous.27 The aim of training is to improve the balance between the affective and cognitive domains.25,28 Affective empathy predicts a good relationship in the caregiver-care recipient dyad, offers positive emotional support to the recipient and is linked to prosocial behavior.29,30 Thus, training in cognitive empathy must not disregard the importance of affective empathy, but rather seek to improve the balance between the two domains.

Empathy training programs conducted with caregivers of older people have been developed to minimize the negative impacts of providing care.31, 32, 33 Such programs identified in the literature have different structures in the form of the presentation of their content, such as simulations, lectures and the presentation of videos, and are conducted either in person, such as through telephone contact (i.e., smartphone), or online.32,34, 35, 36 Empathy training conducted online with a focus on the cognitive domain through activities such as combined lectures and simulations have achieved satisfactory results, with an increase in the score of this domain of empathy and, consequently, a reduction in psychological concerns in individuals who provide care.19

Although there is evidence that empathy training for caregivers can minimize the occurrence of psychological concerns, such as depressive symptoms,31 burnout and stress,37 further evidence is needed to determine the effect on burden, which is the main negative impact of providing care among paid and unpaid caregivers of older people. Thus, the main objective of the present study was to understand the effects of empathy training on empathy and psychological concerns in paid and unpaid caregivers of older people. To achieve this objective, we conducted a randomized, crossover, clinical trial investigating pre-training and post-training levels of psychological concerns and cognitive empathy. Based on this objective, we raised two main hypotheses:

Empathy training with a focus on the cognitive domain is more capable diminishing levels of psychological concerns (e.g., burden, depressive symptoms, psychiatric symptoms and the impact of providing care) compared to health education administered to a control group;

Empathy training is capable of maintaining or increasing levels of empathy, especially in the cognitive domain, over time (i.e., follow-up evaluations at 15, 30 and 60 days).